Substance Use Guidelines Committee, November 2007
The use and abuse of alcohol and other mood-altering substances can be problematic for both patients and the clinicians who are trying to assess such use. However, identification of patients who need referral to substance and alcohol treatment units, as well as those whose risky or harmful use affects their ongoing health, is a crucial part of HIV care.
A recent meta-analysis of studies that address behavioral counseling interventions for risky and harmful alcohol use found that such interventions may help patients reduce alcohol consumption . Risky drinkers are defined as those who consume alcohol above recommended daily, weekly, or per-occasion amounts. Harmful drinkers do not meet criteria for abuse or dependence but experience physical or psychological harm associated with their alcohol use, such as impaired judgment, dysfunctional behavior, or problems with interpersonal relationships. Patients who meet criteria for drug or alcohol dependence should be referred to treatment programs. Brief counseling interventions are appropriate for those with risky or harmful use as defined above, or to help motivate patients with dependence who decline referral for care.
The prevalence of problematic (risky, harmful, or dependent) substance and alcohol use can be as high as 20% to 40% in acute care settings ; however, many patients with substance and alcohol dependence are not identified as having a problem because it is difficult to obtain an accurate history of substance use. Identifying substance use can be a key factor in HIV care, not only to address the problems associated with the substance use per se, but also to help patients adhere to HIV medications.
Clinicians need to be particularly vigilant in screening HIV-infected patients for all levels of alcohol and other substance use and abuse because even intermittent use can interfere with adherence to medications , raise the risk of side effects from medications, and reduce the patient’s ability to practice safer sex.
HIV-infected patients should be screened annually for substance use even if the baseline screen is negative. As patients become more comfortable with their clinician, they may provide a more accurate history regarding sensitive issues, including substance use. Examples of screening instruments that can be easily integrated into primary care practice are provided in Screening Instruments.
- Whitlock EP, Polen MR, Green CA, et al. Behavioral counseling intervention in primary care to reduce risky/harmful alcohol use by adults. A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:557-568. [PubMed]
- Isaacson JH, Schorling JB. Screening for alcohol problems in primary care. Med Clin North Am 1999; 83:1547-1563, viii. [PubMed]
- Murphy DA, Marelich WD, Hoffman D, et al. Predictors of antiretroviral adherence. AIDS Care 2004;16:471-484. [PubMed]
Basic principles of screening:
- Ask about current and past substance use in a nonjudgmental way.
- Ask about the most commonly used recreational drugs including alcohol, marijuana, stimulants (cocaine including crack cocaine, methamphetamines), opiates, and benzodiazepines. A separate question about the use and abuse of prescription opiates and benzodiazepines is also important.
- Ask if the patient, or those around him/her, has any perception of having a substance use problem, now or in the past.
- If patient denies substance use, but historical, physical, or laboratory indicators suggest it, continue to inquire about substance use at subsequent visits.
Common Indicators of Possible Substance and/or Alcohol Use or Abuse
- History of referrals or participation in substance/alcohol treatment programs
- Trauma, especially after drinking/substance use
- Legal problems
- Job loss, turnover, downward mobility
- Relationship problems
- Medical history: seizures, pancreatitis, liver disease, cytopenias, tachyarrhythmias, endocarditis, abscesses
- History of psychiatric symptoms, especially affective disorders
- History of or current heavy smoking
- Physical signs and associated substances:
- Hypertension: Alcohol, cocaine, methamphetamine
- Resting tachycardia: Alcohol, cocaine, marijuana, methamphetamine
- Tremor: Alcohol withdrawal or stimulant intoxication
- Alcohol on breath
- Dilated pupils: Stimulant use or sedative withdrawal
- Small pupils: Opiate use
- Needle marks/tracks: Any injection drug use
- Bruises or healed fractures, especially of the ribs: Alcohol
- Puffy facies: Alcohol
- Hepatomegaly: Alcohol
- Weight loss: Cocaine, methamphetamine
- Laboratory values: Except under certain circumstances (e.g., suspected drug-induced coma), performing toxicology testing without the patient’s consent is not appropriate.
- Elevated mean cell volume (MCV), if not taking zidovudine
- Elevated GGT: Associated with alcoholic liver disease, and a more sensitive marker than AST
- Decreased serum B12
- Urine drug screens: Use in diagnosis and monitoring
- Blood alcohol levels: Use in diagnosis and monitoring
To optimize the reliability of the information being gathered, screening should be performed when the patient does not have alcohol on his/her breath or appear to be under the influence of any drug. Screening questions that vary from brief to more detailed should be asked, using the more detailed questions to explore situations which are suspicious for problem drinking/substance use. Because polydrug use is not uncommon in substance-using patients, clinicians should investigate for the use of additional substances when the patient discloses use of a particular substance or when indicators are present for the use of a particular substance. The more comprehensive an understanding the clinician has regarding the full spectrum of the patient’s drug use, the higher the quality of care that can be provided.
Clinicians should be comfortable with inquiring about substance use, which, in turn, will allow the patient to feel at ease when providing information. Patients often minimize or deny alcohol and substance use because of the stigma associated with addiction and also because they are struggling with its use and report what they want to be true. Clinicians can generally obtain a more accurate history by asking questions in a way that gives the patient permission to tell the truth. Striving to be nonjudgmental will help the clinician build a trusting relationship and will encourage the patient to give honest answers. This is a skill that can be applied to many other aspects of HIV care, including adherence counseling and sexual history-taking.
Establishing good rapport with patients is important and can be facilitated through a variety of questions. The clinician should consider:
- Rephrasing questions. Instead of asking: “Do you drink?” the clinician can ask: “What do you like to drink: beer, wine, or liquor?”
- If the patient says s/he doesn’t drink, then ask: “Not even for a wedding? Or New Year’s?” (or some other socially acceptable time).
- If the patient continues to deny drinking or substance use, ask: “Was there ever a time when you did drink (or use drugs)?”
- Phrasing a question with “even once,” such as: “Did you ever even once shoot up to get high?” may provide useful information for the clinician.
- Assessing whether the patient is actively using alcohol or drugs – this is a key issue for determining medical care. Example: “When was the last time you had even a sip?” may be a good way to find out about current drinking.
- Sounding comfortable with the questions asked, using street terms for substances and substance use. Example: “So when was the last time you smoked any weed?” may get a more accurate answer than: “Do you use marijuana?”
- Seeking assistance when necessary. Clinicians who are uncomfortable asking questions about substance use and alcohol issues may want to delegate screening to another member of the healthcare team; however, physicians and mid-level clinicians are in a unique position as primary care providers to help patients with these issues.
Identifying Clinical Indicators
Some common clinical indicators may facilitate identification of alcohol and substance use problems. Many surrogate markers listed in Common Indicators of Possible Substance and/or Alcohol Use/Abuse can follow from other causes, particularly in the setting of HIV or HIV/hepatitis C co-infection; however, these indicators should prompt a screen or re-screen for substance/alcohol problems.
Heavy smoking is often a surrogate marker of other substance and alcohol dependence and should prompt the clinician to screen in more detail for other addictions. Screening for nicotine addiction itself is also an important aspect of HIV primary care. The Fagerstrom Test for Nicotine Dependence has been used for this purpose and can be beneficial in guiding the patient and clinician toward appropriate therapy . See Smoking Cessation in HIV-Infected Patients for more information concerning smoking.
- Heatherton TF, Kozlowski LT, Frecker RC, et al. The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991;86:1119-1127. [PubMed]
Screening instruments, such as those listed below, can be effective in assessing whether a given patient has a problem with substance use, but the informal or expanded history-taking illustrated in the General Approach to Screening for Substance Use often yields important information as well. The screening tools were developed with a strict adherence to scripted questions in order to improve the validity of the scoring. Patients’ responses to the scripted questions often provide useful prompts for further exploration by clinicians.
Many attempts have been made to develop a sensitive and efficient screening tool to identify patients with alcohol and substance use problems. No single set of questions has been shown to be better than any other, and there are no large studies examining or comparing these tools in HIV-infected patients. Clinicians should adapt their questions to the individual patient and his/her situation and needs; some familiar tools, such as the CAGE questionnaire, are not as sensitive in younger patients.
Some screening tools for substance use/abuse have adopted many of the same questions as those used for screening alcohol problems. Some clinicians find it helpful to modify screening tools that have been validated using alcohol questions to also include other drugs. For example, “How often do you have a drink containing alcohol or use drugs?”
Short screening instruments are useful in the primary care setting and have been shown to identify patients with substance use problems/addiction as effectively as longer screens. Links below are to specific screening instruments and to other resources.
Common Screening Tools to Identify Substance Use or Alcohol Problems
- Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) (PDF): Developed for the WHO to detect and manage substance use and related problems in primary care and general medical care settings.
- Alcohol Use Disorders Identification Test (AUDIT): Developed in 1982 by the WHO as a simple way to screen and identify people at risk of alcohol problems.
- AUDIT-C (PDF): AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence). The AUDIT-C is a modified version of the 10-question AUDIT instrument.
- CAGE: Widely used in a variety of setting and with many target populations.
- CAGE-AID (Adapted to Include Drugs): The CAGE is a 4-item questionnaire that takes less than 1 minute to administer and score. The target population is adults and adolescents in a primary care setting. CAGE-AID is adapted to include drug use, and is designed for the same target population.
- Fagerstrom Test for Nicotine Dependence: A standard instrument for assessing the intensity of physical addiction to nicotine.
- National Institute on Alcohol Abuse and Alcoholism (NIAAA): Helping Patients Who Drink Too Much: A Clinician’s Guide, 2005 Edition
- NIAA Alcohol Alert: Screening for Alcohol Use and Alcohol Related Problems: Alcohol use screening tool that can be used in a wide variety of medical settings.
- NIAAA: A Pocket Guide for Alcohol Screening and Brief Intervention: Use to screen for heavy drinking and assess for alcohol use disorders.
- SAMHSA: Screening, Brief Intervention, and Referral to Treatment (SBIRT): SBIRT is an approach to the delivery of early intervention and treatment for people with or at risk of developing substance abuse disorders.
- TWEAK Screening Tool: Five questions designed to screen pregnant women for harmful drinking habits.
- Two-Item Conjoint Screen (TICS): A screen consisting of 2 questions on alcohol/drug use in the past year and feeling the need to cut down on use.
A range of substance use treatment referral options is available, and clinicians should be familiar with the alcohol and substance use treatment programs and services in their areas. Patients who are currently using substances or alcohol but have a history of good recovery may need just a simple reminder to return to their previous support systems. Outpatient substance abuse treatment services and Twelve Step programs, such as Alcoholics Anonymous and Narcotics Anonymous, are some of the options available for these patients. Other patients may need referral to inpatient treatment or supportive living. Clinicians who are not addiction specialists should offer referral to programs that can help the patient choose among these options. Active addiction is a complex process and patients often refuse referral for help. See Working With the Active User for guidance in dealing with active users.
Patients with a known history of substance/alcohol dependence are at high risk for relapse, particularly when stressed by a new diagnosis of HIV or its complications. By asking patients who are in early recovery about the date of last use of substances, alcohol, and tobacco at every monitoring visit, clinicians can diagnose relapses earlier and refer patients back into care. Patients who use multiple drugs may succeed at discontinuing the use of one drug while continuing to use others. Clinicians should phrase questions to inquire into the use of other substances as well.
A urine drug screen or blood alcohol level (BAL) should be obtained only with the patient’s consent, except under medically indicated conditions, such as suspected drug overdose, where the results would provide clinically significant information for appropriate treatment decisions. The tests are generally not clinically helpful when performed routinely, but may elucidate a clinical scenario in which substance use is suspected. If the urine drug screen or BAL is obtained and results suggest that the patient has been using alcohol or substances, the clinician should gently challenge the patient’s statement, express concern, and recommend referral to treatment.
Clinicians should give positive feedback to a patient who is engaged in a recovery program. The question: “When did you last drink or use?” can be asked in a supportive fashion. For example, asking the patient: “So how long have you been sober/straight? Is it 6 months? No sips or slips? Great!” can be a simple way to provide support for recovery. Clinicians should also express support for patients who continue to use, but have succeeded in reducing use. If a patient has resumed use after a period of recovery, the clinician should express concern and recommend ways to move back toward recovery.
Substance Use Guidelines Committee, November 2007
|ALL RECOMMENDATIONS: SCREENING AND ONGOING ASSESSMENT|